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It is essential that the documentation in the patient healthcare record is complete, accurate, and timely. Patient health record documentation is at the center of

It is essential that the documentation in the patient healthcare record is complete, accurate, and timely. Patient health record documentation is at the center of quality initiatives. Providers rely on precise diagnosis and procedure codes for determining revenue reimbursement and quality scores. The scores by which providers are measured fall into performance categories such as quality, improvement activities, advancing care information, and cost and resource use. Quality scores inform the data presented to the public regarding hospital quality. They are shared across multiple healthcare organizations, public health officials, and public health organizations. If shared appropriately and reliably, the data can be used to improve public and population health outcomes, enhance communication between providers and public health officials, increase public health reporting and surveillance, and support disease prevention. Therefore, since the patient record documentation is the basis for revenue management and performance scores, it should be of high quality to maximize benefits to patients, providers, and the public overall. Select one performance measurement and respond to these items:

  • Briefly summarize the performance measurement and its key concepts.
  • Explain the significance of the performance measurement to an HIM professional.
  • Explain how you would use the EHR system to evaluate your performance measurement.
  • Create an example of a visual (chart or graph) to illustrate performance over time.
  • Explain how the performance measurement can contribute to the overall concepts of performance management and patient safety.

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